Illustrations by Mark Marturello
Finding new answers to an ‘old’ problem
Of the many triumphs of modern society, our ever-increasing life expectancy may be the greatest achievement. Improved medical knowledge and an enhanced quality of life have allowed people to live to ages once thought impossible. Yet old age is still a relatively recent phenomenon. Only in the last 70 years has it become common to live to see 65, let alone enjoy life beyond that. But as we continue to tack years onto our lives, we face a new and unknown challenge: the aging of America.
The United States faces an unprecedented demographic shift over the next 20 years. Our population is aging rapidly. The oldest members of the baby boom generation have reached retirement age, and 10,000 more hit that mark every day. By 2030, nearly 20 percent of the U.S. will be 65 and older.
Of the many triumphs of modern society, our ever-increasing life expectancy may be the greatest achievement. Improved medical knowledge and an enhanced quality of life have allowed people to live to ages once thought impossible. Yet old age is still a relatively recent phenomenon. Only in the last 70 years has it become common to live to see 65, let alone enjoy life beyond that. But as we continue to tack years onto our lives, we face a new and unknown challenge: the aging of America. The issue is not unique to America. Worldwide, life spans are increasing while birth rates are dropping. Taken with the graying of the baby boomers, these trends create an extraordinary change in the world’s population, where two billion people will be 65 or older by 2050.
The World Health Organization conducted focus groups that identified eight areas in which communities could enhance the quality of life for older adults:
- Outdoor spaces & buildings
- Social participation
- Respect & social inclusion
- Civic participation & employment
- Communication & information
- Community support & health services
“The whole world is aging, especially in urban areas,” says Yogesh Shah, M.D., associate dean of global health at Des Moines University. “If we don’t make changes to our cities, it will be hard for our elderly to live independently.”
Recognizing this “silver tsunami,” the World Health Organization (WHO) in 2006 brought together 33 cities in 22 countries to determine key elements in the urban environment that support active and healthy aging. These cities formed the Global Network of Age-Friendly Cities.
In order to build a framework to assess and improve age-friendliness, the network went straight to the source – seniors. WHO worked with each city to set up focus groups to ask older people, as well as caregivers and service providers, to describe the advantages and challenges of city life. The findings from the focus groups helped establish a set of guidelines to make communities friendlier to older adults. They centered on issues in eight areas of urban living, from health services to social inclusion (see sidebar at left).
Through his work with WHO on global health initiatives, Shah heard about the Age-Friendly Cities program early on and thought it was a perfect fit for Des Moines. His experience as a family physician and geriatrician in small-town Iowa helped him understand the importance of making communities more livable for seniors.
“When I worked in Mount Ayr in 1996, I had a patient who was losing her abilities and had no one to help her, but she didn’t want to give up her independence,” says Shah. “The goal of Age-Friendly Cities is to keep seniors in their own environment and allow them to stay active.”
Shah moved quickly to garner support from DMU President Angela Walker Franklin, Ph.D., Des Moines Mayor Frank Cownie and other key community leaders. He formed a small committee and secured the approval of the city council in July 2011. With the support of the city’s leadership, Des Moines became just the third Age-Friendly City in the United States in September 2011.
“Age-friendly is friendly for all”
As the silver tsunami swells off in the distance, several other cities are taking action to deal with the impending flood of older people. Portland, OR, one of the original cities to join WHO’s global network, played a critical role in the research phase of the project and used that data in crafting a 25-year strategic plan for city development. Atlanta, GA, is working to adapt zoning codes for housing and retail to create walkable, lifelong communities.
Cities are quickly realizing that making changes to support an older population creates advantages for people of all ages. Common-sense solutions to improve the physical environment, access to services and public transportation are smart growth strategies that make a community more livable overall.
of the U.S. population will be 65 or older
“An Age-Friendly City benefits everybody. It will be good for young people, the disabled and others,” Shah says. “For example, wider sidewalks and longer walk lights benefit all pedestrians, not just the elderly. Age-friendly is friendly for all.”
New York, perceived as a bustling metropolis most suited for the young, has become the model for age-friendly. No city has worked faster to incorporate the concept of active aging in all aspects of urban life. Since launching Age-Friendly NYC in 2007, the city has already responded with 59 initiatives, from adding benches at bus stops to expanding pool hours to accommodate senior swimmers.
But New York is not just plucking low-hanging fruit; the city has developed some innovative approaches to age-friendly. Local artists provide cultural activities and art classes at senior centers in exchange for studio space. City school buses, typically idle during the school day, shuttle older adults from senior centers to supermarkets. A volunteer time banking network allows people of different ages and skills to help one another by trading services.
Even businesses are getting involved. Seeing it as an opportunity to attract new customers with spending power, local establishments are catering to the needs of seniors. More than 1,000 businesses citywide have received an age-friendly designation for offering services geared toward older consumers, such as public restrooms, home delivery and senior discounts.
“It made perfect sense”
At the same time Des Moines was launching its age-friendly program, AARP was exploring a national initiative to expand the concept across the United States. With three Age-Friendly Cities already established in the U.S., the organization decided against reinventing the wheel and instead partnered with WHO to identify communities for membership in the global network.
“The country is being confronted by this aging demographic and we know that many communities are not prepared,” explains Jeanne Anthony, senior project manager for AARP Livable Communities. “AARP has promoted livable communities for some time. Age-Friendly Cities was an opportunity to help communities prepare and plan. It made perfect sense to us.”
AARP formally launched its Network of Age-Friendly Communities in April 2012 with pilot programs in eight cities. The program provides a system for AARP state offices to collaborate with local officials to recognize and implement improvements that make communities friendlier to older residents.
“We try to create resources for the state offices, local officials and communities that align with the eight domains established by WHO,” Anthony says. “We have a new website [www.aarp.org/livable] where we can share what other communities have done – their stories and best practices.”
Since joining Des Moines’ age-friendly movement, Kent Sovern, state director of AARP Iowa, has taken a leadership position on the committee. He immediately realized the importance of AARP’s role in connecting city leaders with the community’s seniors.
“AARP’s role locally is to convene, endorse, encourage and invest,” Sovern says. “We are able to take the lead in bringing people together in the community and encouraging AARP members to be a part of the process.”
To get the ball rolling, AARP Iowa organized a series of neighborhood meetings to introduce people to the Age-Friendly City template and get a general idea of the needs and priorities of Des Moines’ seniors. The organization also developed and distributed a survey to 6,000 seniors, asking, “What affects your ability to live your best life in your community?” Results of the survey still need to be analyzed but will lay the groundwork for the effort moving forward.
“With this survey, we’ll have a pretty good idea of what criteria demand our attention,” says Sovern. “We’ll have a general sense of the level of satisfaction that folks have with different aspects of Age-Friendly and be able to make recommendations on the essential features needed in our community.”
Recommendations will be citywide as well as customized down to the neighborhood level. AARP Iowa plans to survey surrounding communities next, with the state’s other metropolitan areas planned in the future. Meanwhile, work continues to weave the Age-Friendly City concept into other community initiatives. Sovern and other committee members have worked with leaders of the region’s major planning efforts, DART 2025, Capital Crossroads and the Tomorrow Plan, to incorporate age-friendly features into Des Moines’ future development.
“Age-Friendly Cities isn’t a stand-alone plan,” he says. “It’s been worked into a greater community vision. It’s exciting to think about these broader public policy issues to meet the needs of all ages with the general goal of people living their best life in the community.”
“Des Moines already has a lot in place and is further along than most cities,” adds Joel Olah, Ph.D., co-chair of Des Moines’ Age-Friendly City committee and executive director of Aging Resources of Central Iowa. “If Des Moines is ranked as a top city for young professionals, why can’t it be the same for seniors?”
Care to change
Comments from AARP Iowa’s preliminary neighborhood meetings showed that Des Moines has the necessary health care services in place. However, that access is lacking in most cities. Considering the transportation challenges of many seniors, health care providers face a major hurdle in treating the older population.
“People outlive their driving abilities by years,” Anthony says. “In suburban-style communities, which are predominant throughout the country, people don’t have access to services if they can’t drive. They can’t readily access services by walking, either.”
Hospital systems have responded by extending their services to the neighborhood level. “We’re already seeing a shift to more urgent care and outpatient services away from the hospitals,” says Sovern. “The question, I think, is how will we organize ourselves to deliver services effectively?”
Of greater concern is the increasing burden an older demographic will place on a health care industry already encountering major workforce shortages. Advanced age brings a host of chronic health issues, resulting from decades of unhealthy habits and largely sedentary lifestyles. Providers, especially those in primary care, will be taxed to meet the health care demands of an aging population.
“The health system is not structured to allow adequate time to spend with older patients,” claims Anthony. “Many doctors are in a difficult space. They need to treat patients holistically, but how do you treat the whole patient in just 15 minutes?”
The Affordable Care Act, although controversial, aims to remedy the situation by changing the focus to quality of care instead of quantity. It also emphasizes disease prevention through the promotion of health and wellness to people young and old. “As clinicians, promoting active aging for ourselves, our patients and others is critical,” says Shah.
No easy fix
The greatest threat to cities in the quest for age-friendliness is not in logistics, planning or even finances; it is the negative attitude toward the older population. In our society, there exists a false perception that seniors want to be left alone to live out their remaining years. Older adults are often forgotten soon after retirement and become isolated from the rest of the community.
“The biggest obstacle we face in making the world more age-friendly is actually cultural,” says Shah. “We can make sidewalks wider, improve transportation and make health care more accessible. That’s all easy. But the cultural aspect isn’t a fast fix. It will take time to change that mindset.”
Sovern agrees. “Social capital is crucial. Seniors want to continue to be engaged in their community, and more specifically, their neighborhood,” he says. “We need to keep them involved in events, employment and civic life.”
are older than 55, with 21 percent older than 65
Des Moines University is doing its part to change these long-held attitudes and beliefs. The Senior Health Fair, held annually in November, offers health education and medical screenings for adults 50 and older in the community, and at the same time provides DMU students with direct interactions with seniors. This year, nearly 450 seniors came to campus to visit more than 50 booths manned by community service vendors and student groups, including one that focused on social inclusion.
The University also regularly partners with Wesley Acres, a neighboring retirement community. The physical therapy department recently teamed with Wesley and the Iowa Department of Public Health to host an event on Fall Prevention Awareness Day. Students from the Geriatrics Club (motto: “putting twinkles in your wrinkles”) frequently visit the center to better understand seniors and get hands-on experience working with them.
Geriatrics Club Co-Presidents Michael Eastman and Lindsey Miller, both members of the College of Osteopathic Medicine Class of 2015, are among the DMU students who frequent Wesley Acres for a weekly informal lunch with residents of its dementia unit.
“It’s good for the seniors but also good training for us,” Eastman says. “As doctors, we’re pressed for time, but the lunch is time to have fun. Diseases like dementia don’t kill your sense of humor or ability to laugh.”
Miller agrees such interactions break down stigmas about older people. She “spent a lot of time” in the nursing home with her grandfather, who had Alzheimer’s disease; she also experienced her grandmother’s end of life from cancer. “Now aspects of health care are working to improve bedside manner,” she says. “Geriatric care is not to find a cure for every condition, but to improve functionality and quality of life.”
Shah echoes that partnerships like the one DMU enjoys with Wesley Acres are mutually beneficial. DMU faculty, staff and students can learn from the residents while making them feel like part of society. It is part of the University’s commitment to promoting lifelong learning and wellness in the community.
Including seniors socially benefits everyone, the Geriatrics Club members emphasize. Eastman, who helped his mother – in her 70s – relocate to Des Moines when he enrolled at DMU, is ardent about that.
“We seclude our seniors. With the modern family structure, there are people who get left behind,” he says. “But there are important roles for grandparents in families and society.”
A block north of DMU on Ingersoll Avenue, efforts are under way to revitalize the streetscape to help breathe new life into an aging neighborhood and further benefit aging citizens. The enhancements give pedestrians easy access to the diverse mix of restaurants, retail, services and entertainment. Wide sidewalks, curb cuts, new bike lanes and longer crosswalk times not only benefit seniors but also the disabled, bicyclists and mothers pushing strollers.
Infrastructure improvements like this were meant to boost economic development, but they just so happen to be the kind of changes that earned Des Moines its Age-Friendly City status. As other communities across the country look to join the network, another demographic shift could occur: baby boomers spurning the traditional migration south in favor of vibrant cities known for their age-friendly amenities. Places like Portland, New York, Atlanta – and Des Moines.
“Better to wear out than rust out”
When you ask Michael Eastman and Lindsey Miller why they’re interested in geriatrics, the two DMU osteopathic students describe the older family members who have inspired them. They then point out the wisdom senior citizens have to offer.
“It’s almost selfish,” says Eastman, who with Miller co-presides over the DMU Geriatrics Club. “I want to learn from them so I know how I can stay healthy and enjoy life.”
There are lots of such lessons to be learned from Lee and Clancy Dickson and Mary Anne and Dean Green. The residents of Wesley Acres, the WesleyLife retirement and health care community next door to DMU, embraced aging long before the World Health Organization made “age-friendly” cool. Both couples moved into the facility’s independent living residence when most of their peers wouldn’t dare utter “retirement home.”
“All our friends couldn’t believe we wanted to move into a nursing home,” says Mary Anne. “We loved our house, but we didn’t need all that room anymore.”
The two couples view aging as just another of life’s transitions to be planned yet enjoyed. For them, moving to Wesley Acres isn’t at all about being sedentary shut-ins; rather, it’s being members of a vibrant, active and engaging community.
On Wednesdays, Mary Anne participates in a water aerobics class and then plays the piano in Wesley Acres’ Alzheimer’s unit. She also plays the organ during Sunday chapel and does all the buying for the facility’s gift and coffee shop, the Gather and Gab. Dean often staffs the shop and enjoys fishing with Clancy, who is floor representative on a residents’ forum. Lee chairs the Wesley Acres Council and is in her 15th year of volunteering in hospice. Both couples exercise.
“At some point in your life, you’re not going to be able to do some things,” says Clancy, 90. He and Lee, 86, recently gave their golf clubs to grandchildren. “So you just let it go and do something else.”
Both couples credit good genes for their health. Clancy, for example, played ice hockey in his 70s and softball in his 80s. They have had their physical challenges, however. Last year, Mary Anne had a hip replaced; in 2010, Clancy suffered a stroke on his and Lee’s 55th wedding anniversary. As with so many hardships in life, their positive attitudes helped them cope.
“Clancy has always had a sense of humor,” Lee says. “Even when he was recovering in the health care center, everyone loved him. He’d joke with people and never complain.”
“We have our creaks and groans,” notes Dean, to which Mary Anne adds, “but my mother always said it’s better to wear out than rust out.”
The Greens and Dicksons are great examples of people who understand that “wellness is truly all-encompassing,” says Mary McCarthy, M.P.H., CHES, ACSM. She became Wesley Acres’ first wellness director in 2004; currently, 80 percent of the facility’s residents participate in the program, far above the initially hoped-for 35 percent.
“Wellness is not just about fitness. It’s also your social, emotional, intellectual dimensions,” she says. “It’s mind, body and spirit.”
Participating last fall in a one-mile walk with several DMU and Wesley Acres staff, Lee Dickson noted that having friends of all ages is a plus to healthy aging. Chatting later in her and Clancy’s apartment, she cites another.
“We have a small glass of wine every day at four o’clock,” she says.
Age-friendly shouldn’t be anti-aging
In discussions about healthy aging and effective health care for senior citizens, Christopher Unrein, D.O.’88, FACP, CMD, doesn’t want some critical concepts to get lost: that having a good, long life should include the chance to plan a good death; that age-friendly should include letting people get old; and that, given one’s health circumstances, it can be okay to let go.
“We’re a death-denying, youth-oriented society. In AARP’s magazine, you don’t see anyone who’s elderly,” he says. “We need a social attitude change.”
Unrein’s views are shaped by his diverse practice background, from general internal medicine to geriatrics and now focused on long-term care. Board-certified in internal medicine and in hospice care and palliative medicine, he is executive medical director of Hospice of St. John in Englewood, CO, and director of its hospice and palliative medicine fellowship. President-elect of the Colorado Society of Osteopathic Medicine, he serves on the faculty at Rocky Vista University’s College of Osteopathic Medicine and the University of Colorado-Denver School of Medicine.
“I find caring for the elderly the most rewarding medical practice,” he says. “I emphasize their quality of life. It suits me, as does osteopathic medicine; I call it high-touch, low-tech care. It’s more about managing patients’ symptoms than diagnosing and curing them.”
That approach doesn’t always jive with physicians, Unrein acknowledges – and understands. Practicing in internal medicine in his 30s, he “came from the viewpoint of wanting to fix things and be the shining knight on the white horse.”
“I know people who think going into nursing homes means the physician failed,” he adds.
Palliative care also is “undervalued” by the federal government, Unrein notes. Medicare reimbursement for consultation on advanced care and end-of-life planning came into question during the health care reform debate, when vice presidential candidate Sarah Palin conjured images of government “death panels” that would ration and restrict health care services for Grandma.
“The death panel nonsense torpedoed having these high-quality and frank discussions,” Unrein says. “But palliative and hospice care is more cost-effective than having people do the revolving-door thing in and out of the hospital. Plus it enhances their quality of life.”
Unrein believes the growing numbers of elderly people and attitudes of baby boomers – who believe there are “worse things than dying” – will tip a shift to more end-of-life planning.
“Educating people on having these conversations early is hugely important,” he says. “Knowing a person’s wishes can ease uncertainties of their loved ones, ensure the person is comfortable, help avoid thousands of dollars in medical costs and allow a celebration of the person’s life.”